As a pain management specialist in New York, Corey Hunter, M.D., hears many questions from patients living with chronic pain, including pain from diabetic neuropathy. Here, he answers the most frequently asked questions...

Why does it feel like my skin is burning, numb or like pins and needles? What is causing these symptoms? Typically, a healthy nerve will send a signal only when it’s stimulated, e.g., a nerve in the hand that senses temperature will stay quiet until the hand gets near the flame on the stove. However, an injured nerve is like a broken telephone that rings when no one is calling (burning) or is unable to get a dial tone when you need to make a call (numbness).

Even when it has nothing important to say to the brain, the nerve will send a message. The brain can interpret this confused message as pain or strange sensations like “pins and needles.”

Over time, the spinal cord can become accustomed to getting bombarded by a nerve that never seems to turn off, and makes adjustments for it. So, even once the nerve manages to stop firing, the spinal cord has become so used to sending that signal that it will keep doing it on its own.

My usual pain relievers – acetaminophen (Tylenol), ibuprofen (Motrin), or even the combination of acetaminophen and oxycodone (Percocet) – aren’t working. Why? There are two basic types of pain: nocioceptive and neuropathic.

Nocioceptive pain is from an injury to a part of the body, such as a broken arm, and the nerves in your arms or legs tell the brain that something was hurt, and we feel pain.

Neuropathic pain is from an injury to the nerve itself. It’s pain that’s vague and nondescript, such as burning pain in the feet resulting from uncontrolled/too high blood sugars for too long and injuring the nerves in the feet).

Medications such as acetaminophen, ibuprofen and the acetaminophen and oxycodone combination effectively treat nocioceptive pain. They can decrease the inflammation at the injury or dull the pain message being sent altogether.

These medications and hydrocodone combination (Vicodin) only “take the edge off,” and the burning and/or painful numbness seems to always be present.

However, when the pain is coming from an injured nerve, the effect [of these medications] will be limited. That’s where neuropathic pain medications become important because they act on the nervous system directly.

What tests can you order to see what’s happening? A good test to evaluate the function and integrity of the nervous system is a nerve conduction study (NCV)/ electromyography (EMG). The NCV tests how fast a nerve can send a signal and how much of that signal is getting through. The EMG tests the interaction of those nerves with the muscles which gives the doctor an idea of whether the nerves are healthy.

What medications can I take for neuropathic pain? Medications such as antidepressants (e.g., duloxetine) and anticonvulsants (e.g., gabapentin and pregabalin) have been the mainstay of neuropathic pain treatment.

Tizanidine (Zanaflex), a muscle relaxer, has been used fairly frequently for neuropathy. A small daily dose is effective.

Methadone, a powerful pain reliever, and an older medication called ketamine have been found to be quite effective for neuropathy. Ketamine [an anesthetic] can be used topically when added as the active ingredient in a cream or infused intravenously in a hospital setting.

How much relief can I expect? The amount of relief varies from one patient to the next and it’s nearly impossible to predict. With many of the medications for neuropathic pain treatment, your doctor will need to start with a small amount and slowly increase it over time to an effective dose.

Other medications simply need time to build up in your body. It’s important to ask your doctor what to expect with the medication(s) being prescribed: dosing, side effects, degree of relief, improvement in quality life and physical function…

My last doctor requested drug tests every time I saw him. How can I deal with being treated like an addict? No one sets out to become addicted to prescription pain relievers, but the potential for dependency is always a concern. Because of this, strict monitoring should be in place for any patient on opioids.

[However,] many physicians may not know the most effective way to treat neuropathic pain and so recommend opioids first. It wouldn’t be incorrect if you asked for an alternative therapy.

What treatments are there if the medications don’t work? Physical therapy (PT) typically is prescribed at the very beginning or along with neuropathic pain medication. The prescription should include therapies that aim to decrease the intensity of the pain (i.e. contrast baths) and increase the function of the extremity (i.e. range of motion and strengthening).

If conservative measures fail, a skilled interventional pain physician may attempt to deliver medication by injection to the patient’s pain relay centers to reduce the pain or even turn off the pathway. Other injections may be directed at the nerves believed to be responsible for transmitting the pain. A variety of minimally invasive procedures can offer relief.

Finally, there are implantable devices like spinal cord stimulators (SCS) and intrathecal pumps (ITP). Many physicians describe an SCS as “a pacemaker for the spinal cord.” A battery is implanted just under the skin with a small, flexible lead that goes into the spine and essentially interferes with the cord’s ability to transmit pain.

With an ITP, a reservoir in which the doctor can place pain medications is placed right under the skin. [No battery or lead is required.]

Will the neuropathic pain go away? That depends on the nerve damage. If the injury is mild and the cells that support the nerve are left intact – the neuropathy should improve as the nerve heals. Many times the nerve is injured by something that can be treated or reversed, i.e. a compressed or pinched nerve, chemotherapy or exposure to a toxic chemical. In these cases, whatever is the culprit can simply be removed from the equation and the nerve allowed to heal.

However, if the injuring agent is still present, it’s harder for the nerve to heal. In fact, if the nerve stays injured for too long, the damage can be irreversible. The sooner a neuropathy is treated, the better the chances for a good recovery.

Will the pain get worse? Unfortunately, even some patients under the care of a skilled pain physician from the start will get worse. There’s no way to predict who these patients will be.

Do a lot of your patients use multiple therapies – e.g., prescription medications, acupuncture and physical therapy – for relief of their neuropathic pain? Treating pain should be thought of like climbing stairs. The first step should include the most basic therapy, like PT and an over-the-counter pain reliever.

As more care is needed, we climb to the next step. With each successive step, the more we add. By the third step, a patient may need to be on two different neuropathic pain medications, PT and be scheduled for an injection.

Treatments like acupuncture often are incorporated early on, as well. We call this a “multidisciplinary approach.”

The idea is to not assume there’s simply one main contributor to the pain. By spreading out the focus, the patient benefits from the idea of “casting a large net” and seeing which treatment works best.

Corey W. Hunter, M.D., is a pain management specialist working at the New York Pain Management Group and is a member of The Neuropathy Association’s Neuropathic Pain Management Medical Advisory Council.

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